Journal of

Clinical Medicine

Article

A Shared Decision-Making Approach toTelemedicine: Engaging Rural Patients inGlycemic Management

Michelle L. Griffith 1, Linda Siminerio 1, Tammie Payne 2 and Jodi Krall 3,*1 Department of Medicine, Division of Endocrinology and Metabolism, University of Pittsburgh,

Pittsburgh, PA 15213, USA; griffithml@upmc.edu (M.L.G.); similx@upmc.edu (L.S.)2 UPMC Bedford Memorial Hospital, Everett, PA 15537, USA; paynetm@upmc.edu3 University of Pittsburgh Diabetes Institute, Pittsburgh, PA 15213, USA* Correspondence: stottsj@upmc.edu; Tel.: +1-412-692-7154

Academic Editors: Yolanda Blanco, Núria Solà-Valls, Rajender Gattu and Richard LichensteinReceived: 25 October 2016; Accepted: 13 November 2016; Published: 17 November 2016

Abstract: Telemedicine can connect specialist health care providers with patients in remote andunderserved areas. It is especially relevant in diabetes care, where a proliferation of treatment optionshas added further complexity to the care of an already complex, highly prevalent disease. Recentdevelopments in health reform encourage delivery systems to use team-based models and engagepatients in shared decision-making (SDM), where patients and providers together make health caredecisions that are tailored to the specific characteristics and values of the patient. The goal of thisproject was to design, integrate, and evaluate a team-based, SDM approach delivered to patientswith diabetes in a rural community, building upon the previously established telemedicine for reach,education, access, and treatment (TREAT) model. Patients in this feasibility study demonstratedimprovement in hemoglobin A1c values, and reported better understanding of diabetes. Providersreported the SDM aids increased cohesion among team members (including patients) and facilitatedpatient education and behavioral goal setting. This project demonstrated that SDM could beintegrated into the workflow of a telemedicine team visit with good provider and patient satisfaction.

Keywords: telemedicine; diabetes; shared decision-making; team-based model

1. Introduction

Diabetes is complex and highly prevalent, and under-served rural communities carrya disproportionate burden of the disease. Studies have shown that patients in rural communitiesunfortunately do not receive the same number and type of chronic care services, including diabetesservices, as their urban counterparts [1]. Telemedicine, the application of telecommunicationstechnology used to connect providers and patients who are geographically separated, is being exploredin an effort to reach remote and underserved areas [2,3]. Telemedicine approaches are particularlyrelevant for diabetes. Optimal diabetes care requires active patient self-management, including dietarymonitoring and self-monitoring of blood glucose along with medication adjustments guided by a healthcare provider. In fact, diabetes has been reported by primary care providers (PCPs), who provide themajority of diabetes care [4–6], to be more difficult to manage given the limited time for visits [7,8].A rapid increase in novel treatment options in recent years adds to the complexity of diabetes care andincreases the demand for specialty expertise and team-based services to complement primary care.

Despite progress of available therapies, patients can still have challenges in meeting target goals [9]and experience distress related to their treatment plan [10–12]. The influx of new and sophisticatedtherapies increases the importance of methods, such as shared decision-making (SDM), to facilitate

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communication about options and engage patients as active participants in their diabetes managementdecisions. SDM encourages providers and patients to collaboratively negotiate health-related decisions,taking into account scientific evidence as well as patient needs and preferences [13,14]. Decision aids,such as brochures or graphics, can be used by health care professionals to introduce patients totreatment options, outcomes, risks and benefits. While such aids are primarily used to compare varioustreatment options, they can also be used to familiarize patients with models of care and key diseasemanagement concepts. Within the context of diabetes, SDM and team-based models have been shownto be effective elements in improving diabetes self-management behaviors and outcomes [15,16].

Using a team-based approach delivered via the telemedicine for reach, education, access andtreatment (TREAT) intervention, investigators at the University of Pittsburgh Medical Center (UPMC)demonstrated improvement in diabetes clinical outcomes, including improvement in hemoglobin A1c(HbA1c), along with improvements in patient self-care, empowerment, reduced diabetes distressand high provider/patient satisfaction [17–19]. The TREAT model includes an endocrinologistproviding consultation via videoconferencing and a nurse diabetes educator (DE) at the patient’s side,who provides associated diabetes self-management education and support. The physician and diabeteseducator are both integral parts of the TREAT care team, and previous studies have shown that patientsacknowledged the importance of both [19].

Although shown to be effective and well-received [17–19], the TREAT study revealed that patientsare unfamiliar with team-based care, particularly when provided in a telemedicine format. Specifically,a need was identified to help prepare patients to engage in discussions about glycemic managementand introduce them to the various members of the TREAT team. Building on the TREAT model, thepurpose of this feasibility project was to create, integrate and evaluate a SDM approach that could beused in this telemedicine model of care. Goals included enhancing the patient’s understanding of keyoutcome measures such as HbA1C, and enhancing the patient’s understanding of the roles of differentproviders in the TREAT model. Additionally, the project sought to increase patient engagement inmedical decisions, thereby improving team communication and incorporating the patient more fullyinto the care team.

2. Methods

2.1. Recruitment and Setting

Patients with type 2 diabetes mellitus (T2D) residing in a medically underserved rural community,and referred by their local PCP and scheduled for a TREAT telemedicine glycemic consultationat a rural hospital clinic as part of usual practice were invited to participate in this project. Thisproject was approved as a Quality Improvement project (Project #0001366) by the UPMC QualityReview Committee.

2.2. Intervention

SDM Aids: To help inform and engage patients in the TREAT process, two SDM aids weredeveloped. The first aid was designed to familiarize patients with the TREAT delivery model anda team-based approach to care. It included a brief description outlining the telemedicine visit andgraphically highlighting the roles of each TREAT team member, which included the referring PCP,endocrinologist and DE as well as the patient (Figure 1). The second aid, shown in Figure 2, centered onglycemic control, specifically addressing HbA1c since it is central to glycemic management (the focusof the TREAT visits). Key elements of SDM were integrated into the HbA1c aid including providinginformation in a simple and meaningful way, describing risks and benefits, and incorporating tools toenable patients to evaluate their options and make decisions. In this case, decisions related to settingan HbA1c target goal and determining behavioral strategies to help meet that goal.

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 Figure 1. The TREAT team. 

 Figure 2. HbA1c decision aid. 

SDM Training: Providers were trained on how to incorporate the content and SDM approach into current practice with  the goal of empowering  the patient  to be an active participant. Scripts were developed to guide discussions about SDM aids with patients. 

SDM Process: The SDM process, depicted in Figure 3, was initiated by mailing SDM aids to the patient  when  the  telemedicine  visit  was  scheduled.  Prior  to  the  TREAT  consult,  the  diabetes educator  called  the  patient  to  encourage  him/her  to  familiarize  themselves with  the  SDM  aids, consider  the  information  contained within,  and  answer  any questions  about  the upcoming visit. During the TREAT consult, the HbA1c decision aid was used as a supplement and guide to help the patient feel comfortable with the structure of the visit and empowered to be an active participant. 

Figure 1. The TREAT team.

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 Figure 1. The TREAT team. 

 Figure 2. HbA1c decision aid. 

SDM Training: Providers were trained on how to incorporate the content and SDM approach into current practice with  the goal of empowering  the patient  to be an active participant. Scripts were developed to guide discussions about SDM aids with patients. 

SDM Process: The SDM process, depicted in Figure 3, was initiated by mailing SDM aids to the patient  when  the  telemedicine  visit  was  scheduled.  Prior  to  the  TREAT  consult,  the  diabetes educator  called  the  patient  to  encourage  him/her  to  familiarize  themselves with  the  SDM  aids, consider  the  information  contained within,  and  answer  any questions  about  the upcoming visit. During the TREAT consult, the HbA1c decision aid was used as a supplement and guide to help the patient feel comfortable with the structure of the visit and empowered to be an active participant. 

Figure 2. HbA1c decision aid.

SDM Training: Providers were trained on how to incorporate the content and SDM approachinto current practice with the goal of empowering the patient to be an active participant. Scripts weredeveloped to guide discussions about SDM aids with patients.

SDM Process: The SDM process, depicted in Figure 3, was initiated by mailing SDM aids to thepatient when the telemedicine visit was scheduled. Prior to the TREAT consult, the diabetes educatorcalled the patient to encourage him/her to familiarize themselves with the SDM aids, consider theinformation contained within, and answer any questions about the upcoming visit. During the

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TREAT consult, the HbA1c decision aid was used as a supplement and guide to help the patient feelcomfortable with the structure of the visit and empowered to be an active participant. The aid was alsoused by the endocrinologist to collaboratively set an HbA1c target goal with the patient. At the end ofthe visit, the DE reviewed the experience with the patient and used the HbA1c tool to help guide thepatient in identifying a behavioral goal to support their HbA1c target. The DE then prepared a takehome summary that included HbA1c and behavioral goals and the patient’s decisions regarding thenext steps in his/her treatment plan. The patient’s behavioral goal was included in the office visit noteand transmitted to the PCP. On return visits, care was taken to discuss progress with the behavioralgoal early in the visit.

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The aid was also used by the endocrinologist to collaboratively set an HbA1c target goal with the patient. At the end of the visit, the DE reviewed the experience with the patient and used the HbA1c tool to help guide the patient in identifying a behavioral goal to support their HbA1c target. The DE then prepared a take home summary that  included HbA1c and behavioral goals and the patient’s decisions  regarding  the  next  steps  in  his/her  treatment  plan.  The  patient’s  behavioral  goal was included  in  the office visit note  and  transmitted  to  the PCP. On  return visits,  care was  taken  to discuss progress with the behavioral goal early in the visit. 

 

Figure  3.  The  telemedicine  for  reach,  education,  access  and  treatment  (TREAT)  glycemic management process. 

2.3. Evaluation 

A feasibility project occurring over a twelve month period was conducted to evaluate patient and  provider  experiences  with  the  SDM  approach.  During  the  project  period,  17  patients  (12 females,  5 males) with T2D  participated  in TREAT  visits;  12  returned  for  at  least  one  quarterly follow‐up visit. Patient behavioral goals established at the end of the TREAT visits were reviewed and  patient  and  provider  feedback  about  their  experiences  was  obtained.  In  addition,  HbA1c (extracted  from  electronic medical  records)  and diabetes  self‐care  behaviors  (measured with  the Summary of Diabetes Self‐Care Activities measure (SDSCA)) [20] were assessed prior to the initial TREAT visit and, on average, six months after baseline  for patients with  follow‐up appointments during the study period. The self‐administered SDSCA questionnaire was used to further examine the benefits associated with the diabetes education portion of the intervention. 

2.4. Data Analysis 

Changes in HbA1c and SDSCA scores were examined by Wilcoxon rank sum test, which is used for small samples and non‐normal distributions. A p < 0.05 was considered significant. All statistical analyses were  performed with  IBM  SPSS  Statistics  for Windows,  version  24  (IBM  Corporation, Armonk, NY, USA). 

3. Results 

Figure 3. The telemedicine for reach, education, access and treatment (TREAT) glycemicmanagement process.

2.3. Evaluation

A feasibility project occurring over a twelve month period was conducted to evaluate patientand provider experiences with the SDM approach. During the project period, 17 patients (12 females,5 males) with T2D participated in TREAT visits; 12 returned for at least one quarterly follow-upvisit. Patient behavioral goals established at the end of the TREAT visits were reviewed and patientand provider feedback about their experiences was obtained. In addition, HbA1c (extracted fromelectronic medical records) and diabetes self-care behaviors (measured with the Summary of DiabetesSelf-Care Activities measure (SDSCA)) [20] were assessed prior to the initial TREAT visit and, onaverage, six months after baseline for patients with follow-up appointments during the study period.The self-administered SDSCA questionnaire was used to further examine the benefits associated withthe diabetes education portion of the intervention.

2.4. Data Analysis

Changes in HbA1c and SDSCA scores were examined by Wilcoxon rank sum test, which is usedfor small samples and non-normal distributions. A p < 0.05 was considered significant. All statisticalanalyses were performed with IBM SPSS Statistics for Windows, version 24 (IBM Corporation, Armonk,NY, USA).

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3. Results

3.1. Goal Setting

All participants (n = 17) established diabetes self-management goals after participating in theTREAT consult, during which the HbA1c SDM aid was reviewed. Most participants chose diet-relatedgoals. A majority of the goals directly referenced improving HbA1c and/or blood glucose levels.Examples of goals are presented in Table 1.

Table 1. Examples of diabetes self-management goals.

Initial HbA1c Goal Detailed Behavioral Goal

HbA1c < 7% by making healthy food choices Increase healthy food choices and limit carbohydrates withmeals; limit sweets to once a week.

Lower HbA1c to 7.5% Cut down on snacks at bedtime.

Lower HbA1c by 1 point to 7.5% by eatinghealthy and monitoring blood sugar Follow Weight Watchers; check blood sugar more routinely.

3.2. Diabetes Outcomes

Diabetes outcomes are shown in Table 2. HbA1c values significantly improved for participantswith follow up visits (n = 12; p = 0.017). Diabetes self-efficacy, blood glucose monitoring, and adherenceto diabetes medication (insulin or oral medications) were reportedly high at baseline and remainedso for approximately 6 months after the initial TREAT visit. Other self-care measures also remainedunchanged with the exception of consumption of high fat foods, which significantly decreased duringthe project period.

Table 2. Diabetes outcomes.

Before InitialTelemedicine Visit ~6 Months Post Visit p-Value

HbA1c (% ± standard deviation) 10.1 ± 1.4 8.6 ± 1.2 <0.05Diabetes Self-Care Measures (days/week) a

Adhere to general diet 4.6 ± 1.9 4.4 ± 1.2 nsConsume 5+ servings fruit & vegetables 4.3 ± 2.1 4.2 ± 1.9 nsConsume high fat foods 4.4 ± 2.4 2.7 ± 1.7 <0.05Monitor blood glucose 5.3 ± 2.3 6 ± 1.4 nsAdhere to insulin or oral medications 7 6.4 ± 2.1 ns

ns = not significant; a Range: 1 to 7 days per week.

3.3. Provider and Patient Feedback

Endocrinologists stated that they were initially skeptical of the SDM approach and concernedthat patients would not be receptive to it. However, endocrinologists and DEs reported positiveexperiences and were impressed by the level of patient engagement. Specifically, providers statedthat the SDM aids increased cohesion among team members (including patients), were useful incommunicating meaning of HbA1c levels, benefits, and risks of glucose control and helped facilitateconversation and behavioral goal setting. Patients expressed a better understanding of diabetes and afeeling of being empowered.

4. Discussion

This project built upon the previously established TREAT care model to develop and integratea SDM tool. Patients were introduced to the care team and the expectations of team members, includingpatients, via descriptions and graphics prior to the first telemedicine visit. They were also provided

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with background education on the importance of HbA1c prior to the first meeting, then were engagedin the process of establishing goals within the shared decision-making framework.

Simple educational aids were shown to be useful in preparing patients for a potentially newexperience with SDM, and that the process was well-accepted by patients. Members of the TREAT teamreported that they were unaware that patients had little understanding in regards to interpreting HbA1Cvalues. They found the SDM aids and process to be useful in supporting knowledge and communication.

Additionally, this project demonstrated that SDM could be integrated into the workflow of a teamvisit with good provider and patient satisfaction. Patient satisfaction is increasingly seen as a criticalmeasure of success in health care. By communicating the patients’ tangible self-care goals to their PCPwithin the assessment and plan, we provided an opportunity for reinforcement during other healthcare visits, without increasing the burden of visit documentation. Given the chronic nature of diabetesand ongoing need for support by all members of the care team, increased communication of specificcare goals may promote and sustain patient adherence and self-care.

Similar to this program, another diabetes SDM program specifically tailored for an underservedAfrican American population included a team-based and educational approach. Participants reportedhigh satisfaction and improved knowledge, along with improvement in decision-making self-efficacyscores, however these changes were not statistically significant [21]. While participants in the TREATSDM intervention experienced improved knowledge and glycemia [19], except for a reduction inconsumption of high fat foods, self-care outcomes were also unchanged in this rural study population.

Limitations of our feasibility project included a relatively small sample size. Sample size waslimited by the availability of telemedicine appointments within the study period (typically 3–4 newpatient appointments per month). The project was not designed to evaluate the effect of the SDMprocess on outcomes such as HbA1c with as much rigor as the original TREAT study [18]. Additionally,longer follow-up is needed to fully evaluate effects on HbA1c and other diabetes outcomes withcontinued care.

While SDM approaches have shown to be beneficial in engaging patients in making informedhealth care decisions, there is limited evidence that SDM influences clinical and behavioraloutcomes [22]. The concept of patient involvement (SDM; informed collaborative choice) is emergingin the literature and requires an accurate and comprehensive assessment of all of the clinical, behavioraland psychosocial themes respective of the specific disease state.

While SDM enhanced our team visit process via telemedicine, these tools are adaptable to othercare environments. Additionally, the telemedicine team approach can be a platform for testing of otherpatient care tools. Overall, these are encouraging findings. As the health care landscape changes andpatients are also treated as “consumers” and expected to make informed choices for their health care,tools that incorporate SDM are even more important.

Acknowledgments: The authors wish to thank the providers and patients who graciously participated in thisproject and the Beckwith Institute for generously providing funding.

Author Contributions: L.S. and J.K. conceived and designed the project and M.L.G. and T.P. performed it. L.S. andJ.K. analyzed the data. M.L.G., L.S. and J.K. prepared the manuscript and T.P. reviewed the manuscript.

Conflicts of Interest: The authors declare no conflict of interest.

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